Provider Demographics
NPI:1477027795
Name:DIALYSIS CENTERS OF NORTHWEST ARKANSAS, LLC
Entity Type:Organization
Organization Name:DIALYSIS CENTERS OF NORTHWEST ARKANSAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STACY
Authorized Official - Last Name:BOMSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-463-7000
Mailing Address - Street 1:107 E MONTE PAINTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4002
Mailing Address - Country:US
Mailing Address - Phone:479-463-7000
Mailing Address - Fax:
Practice Address - Street 1:2158 BUTTERFIELD COACH RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-9142
Practice Address - Country:US
Practice Address - Phone:479-463-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIALYSIS CENTERS OF NORTHWEST ARKANSAS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment